Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Complications of
Pediatric Sinusitis
Naana Afua Jumah, HMS III
Gillian Lieberman, MD
22 January 2007


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

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Outline

Paranasal sinus anatomy
Definitions
Indications for imaging
Imaging modalities
Patient presentation
Summary


Naana Afua Jumah, HMS III

Gillian Lieberman, MD

Sinus Anatomy

Essential Clinical Anatomy, 2002


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Sinus Plain Films

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Sinus Development

Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Sinus

Age (years)
Appearance Maturity

Maxillary

Embryo

12-20


Ethmoid

Birth

12

Sphenoid

1-3

7-14

Frontal

1-4

≥ 12

Kronemer and McAlister, 1997


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Acute vs Chronic Sinusitis

Acute
• Bacterial infection of the paranasal sinuses
• Symptoms last less than 30 days
• Complete resolution

Chronic
• Inflammation of the paranasal sinuses
• Symptoms last more than 90 days
• Persistent residual respiratory symptoms of cough,
rhinorrhea and nasal obstruction

American Academy of Pediatrics, 2001


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Complications of Sinusitis

Orbital

Intracranial

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Edema
Preseptal cellulitis
Postseptal cellulitis
Subperiosteal abscess
Orbital abscess
Cavernous sinus
thrombosis

Epidural empyema
Subdural empyema
Meningitis
Cerebritis
Parenchymal abscess
Mycotic aneurysm
Brain infarction

Subgaleal
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Pott’s puffy tumor
Osteomyelitis

Reid, 2004


Naana Afua Jumah, HMS III

Gillian Lieberman, MD

Indications for Imaging

1. Purulent nasal discharge >10 days
2. Recurrent or persistent clinical sinusitis
3. Preoperative evaluation for functional
endoscopic sinus surgery (FESS)
4. Suspected complication
5. Complex sinus disease
6. Suspected fungal sinusitis
*Imaging is not recommended for
uncomplicated acute sinusitis

American College of Radiology, 2006


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Imaging Modalities to
Diagnose Chronic Sinustis

Plain Film Radiograph
• Low sensitivity and therefore seldom used
• Caldwell (anteroposterior) - frontal, ant ethmoid
• Normal lateral – sphenoid
• Waters (occipitomental) - maxillary, ethmoid
CT
• High sensitivity and therefore the test of choice

• Coronal projection most accurate view of sinus anatomy
• Bone window on bone algorithm for sinus views
• Contrast for intracranial pathology
• Imaging for functional endoscopic sinus surgery (FESS)
• Radiation exposure
American College of Radiology, 2006


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Imaging Modality for
Complications of Sinusitis

MRI
• Intracranial pathology and complex sinus disease
• Lacks bony detail of sinus anatomy
• Long image collection time may require sedation
• No radiation
T1

Anatomy

T1 + Gadolinium

Vasculature, malignancy

T2

Inflammation/fluid


FLAIR

Inflammation

Diffusion weighted

Ischemia

Angiography

Vasculature
American College of Radiology, 2006 and Boyle, 2006


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Abnormal Sinuses in
Children

Incidence of abnormal sinus CT in children
with no history of sinusitis
• 55% had abnormal sinuses
• 33% had air fluid levels in sinuses
High incidence (62%) of viral URI symptoms
or allergic rhinitis within the past 2 weeks

Maning et al, 1996



Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Modified Lund-Mackay
Staging System

Correlation of clinical symptoms of chronic sinusitis with
CT radiographs
• Paranasal sinuses opacification
0 none, 1 partial, 2 complete
Assign score independently to left and right paranasal sinuses

• Osteomeatal complex
0 not occluded, 2 occluded

• Sinus not developed: 0
Score: 0-2 no disease, 3-4 equivocal, ≥5 chronic sinusitis

Bhattacharyya et al, 2004


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient Presentation


Naana Afua Jumah, HMS III
Gillian Lieberman, MD


Patient BE

• 11 year old previously healthy girl
• 4 day history of headache, lethargy,
fever, malaise and sinus congestion
• Seizure during transfer from OSH
• No significant past medical history


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient BE: Sinusitis on CT
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Coronal CT Bone Window

Axial CT Bone Window

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Opacification of the ethmoid sinuses
Opacification of the right maxillary sinus
Concha bullosa a normal variant

Near total opacification of the
frontal sinuses

Courtesy of Dr Hines-Peralta


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

1. Sinusitis
• GERD
• Immune deficiency
syndrome
• URI
2. Trauma
• Hemorrhage
• Edema
3. Allergy
4. Cystic fibrosis

Differential of
Opacified Sinsuses
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Inflammatory mass
• Mucocele
• Cyst
• Pyocele
• Polyp
Malignancy
• Burkitt Lymphoma
• Osteoma
Granulomatous Disease
• Sarcoidosis
• Tuberculosis
Dysfunctional cilia
• Kartagener’s syndrome
• Immotile cilia syndrome
Reeder, 2003


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient BE: Sinusitis on CT
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and MRI

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Axial CT Bone Window

Axial MR T2

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Chronic sinusitis in the maxillary sinuses

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Frothy appearance of acute sinusitis in
the maxillary sinus

Opacification of the ethmoid sinuses
Opacification of the sphenoid sinuses
Fluid in the right mastoid air cells

Courtesy of Dr Hines-Peralta



Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient BE: Subdural
Empyema on Axial MRI

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MR T1 Pre-contrast

MR T1 Post-contrast

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Low signal areas in the anterior and
left lateral temporal lobes indicating
regions of restricted diffusion
suggestive of edema or fluid

Low signal areas in the anterior and
left lateral temporal lobe surrounded
by a rim of enhancement consistent

with empyema
Courtesy of Dr Hines-Peralta


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient BE: Subdural
Empyema on MRI

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Coronoal MR T1 with Contrast

Sagittal MR T1 with Contrast

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Low signal areas surrounded by
a rim of enhancement consistent
with empyema on coronal section

Low signal areas surrounded by
a rim of enhancement consistent
with empyema on sagittal section

Courtesy of Dr Hines-Peralta


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient BE: Meningitis
on MRI

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Axial MR T1 with Contrast
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Focal areas of subtle
enhancement of the meninges
consistent with meningitis

Courtesy of Dr Hines-Peralta


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Companion Patient 1: Meningitis
on MRI

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Axial MR T1 Pre-contrast

Axial MR T1 Post-contrast

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Meninges appear as a ring of low
signal intensity

Ring of enhancement surrounding
the cerebellum consistent with
meningitis

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Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient BE: Cerebral Edema
on MRI

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Axial MR T1 Pre-contrast
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Midline shift

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Compression of the anterior horn of
the lateral ventricle

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Compression of the left posterior
horn of the lateral ventricle

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Diffuse effacement of the cortical gyri
shown best in the left parietal lobe
Courtesy of Dr Hines-Peralta


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient BE: Cerebral Edema
on MRI
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Axial MR T1 Post-contrast

Axial MR T2-weighted

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Low signal areas indicating restricted
diffusion in the frontal lobes bilaterally and
the temporal lobe suggestive of edema or
a fluid collection

High signal areas that follow the pattern
of the gyri in the frontal lobes bilaterally
and the temporal lobe more suggestive of
edema than a fluid collection
Courtesy of Dr Hines-Peralta


Naana Afua Jumah, HMS III
Gillian Lieberman, MD

Patient BE: Cerebral Ischemia
on Diffusion-Weighted Imaging

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Axial MR Diffusion-Weighted Image
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High signal areas that follow the pattern
of the gyri in the frontal lobes bilaterally
and the temporal lobe localizing areas of
cerebral ischemia
Courtesy of Dr Hines-Peralta


Patient BE: Shunt &
Craniectomy on CT

Naana Afua Jumah, HMS III
Gillian Lieberman, MD

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Axial CT Brain Window
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Intraventricular shunt

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Craniectomy site and herniation of the
left cerebral hemisphere beyond the

skull margin

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Post surgical aberrant air collections

Courtesy of Dr Hines-Peralta